Pinpointing severe pancreatitis

While 80% of acute pancreatitis cases never progress beyond mild disease and a short
hospital stay, a minority of patients face life-threatening risks, including organ
damage and necrosis.

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And therein lies the conundrum for hospital physicians—how to identify the
patients most likely to progress to severe disease and how to best manage their care?
Several recent review papers have attempted to shed some light on the management and
epidemiology of this relatively common inflammatory disorder.

Hospitalizations for acute pancreatitis have increased in recent years in line with
rising rates of obesity and gallstones, reaching 275,000 U.S. admissions in 2012, a 15% increase from 2003, according to data published in the December 2015 Gastroenterology. The median length of stay was three days; the in-hospital mortality rate was just
under 1%. But the mortality rate for those who develop organ failure is far higher,
with roughly one-third dying and a similar percentage developing pancreatic necrosis,
according to a meta-analysis of 14 studies published in 2010 in Gastroenterology.

“We take it so seriously because any case—and again it's difficult to
predict—can be a severe case,” said James Haddad, MD, ACP Member, a
general internist and part of the internal medicine staff at Naval Hospital Jacksonville
in Florida.

With no drug available to thwart the worsening of acute pancreatitis, hospital physicians
are left with limited tools to support a patient while the condition runs its course.
Adding to the challenge are debates about the existing risk-scoring methods and uncertainties
about how aggressively to administer fluids for patients who might be more vulnerable
to severe pancreatitis.

Identifying vulnerable patients

Several scoring systems of varying complexity attempt to identify patients with a
higher potential of developing severe disease. But Chris Forsmark, MD, FACP, lead
author of a review about acute pancreatitis published in the Nov. 17, 2016, New England Journal of Medicine (NEJM), is discouraging about their benefit.

They are frequently cumbersome and result in a high rate of false positives, which
means that some patients will be transferred to a more intensive and costlier level
of care that's not needed, he said. “That is, many folks with a high score
do just fine,” said Dr. Forsmark, who is chief of the division of gastroenterology,
hepatology, and nutrition at the University of Florida in Gainesville. “I feel
like there's got to be something better—we just haven't discovered it.”

Instead, he suggested that physicians rely upon their clinical judgment, watching
out for the presence of systemic inflammatory response syndrome along with other risk
factors. “It's not really rocket science,” he said. “The older
they are, the higher their risk. The more severe medical problems they have, the higher
their risk. Obesity is a significant risk factor.”

Not all doctors have extensive experience with acute pancreatitis, and a delay in
identifying those who might progress loses valuable time to intervene, Dr. Haddad
said. For example, a patient admitted overnight might not receive sufficient resuscitation
until a more senior doctor does rounds the next morning. “And then you're behind
the eight ball,” he said.

Any scoring system should be only part of the diagnostic equation, along with a physician's
judgment, Dr. Haddad said. He typically recommends to residents that they calculate
risk using both HAPS (Harmless Acute Pancreatitis Score) and BISAP (Bedside Index
for Severity in Acute Pancreatitis). Both systems are straight-forward and rely on
clinical markers that should have already been collected by ED clinicians, he said.

The strength of BISAP is that it indicates a patient's relative mortality risk, Dr.
Haddad said. HAPS can potentially be used to ease concerns about potential severity.
If all of the diagnostic components are absent, there's a high likelihood the patient
will not progress to severe disease, he said.

But another review, this one for hospitalists published in the Oct. 11, 2016, Journal of Hospital Medicine (JHM), steers doctors away from relying on scoring systems. Instead hospitalists should
focus on laboratory results that indicate inflammation, such as elevations in blood
urea nitrogen (BUN) and hematocrit, or values in liver tests and creatinine that indicate
organ damage, the authors said.

Given that gallstones are the most common cause of acute pancreatitis, implicated
in roughly half of cases, according to the JHM review, an ultrasound should be part of a patient's early diagnostic workup. But a
physician shouldn't order a CT scan initially as part of a diagnostic workup for pancreatitis
and, in fact, the scan could be misleading early on, said Timothy Gardner, MD, associate
professor of medicine at Geisel School of Medicine at Dartmouth in Hanover, N.H.,
and a coauthor on the JHM review.

It's best to defer getting the image for at least 48 to 72 hours, he said. “It
takes a while for things to develop, if there is going to be a complication,”
such as necrosis, he said.

Managing care

A primary reason to identify vulnerable patients shortly after they arrive at the
hospital is so they can be transferred to a higher level of care with closer monitoring,
experts said.

Those measures don't “really keep it from becoming severe,” said Dr.
Forsmark. “It just lets you identify problems as they are developing and hopefully
manage them as best you can.”

Once patients are transferred to a higher-acuity unit, aggressive fluid resuscitation
can be provided. The earlier that those fluids—typically lactated Ringer's
solution—are started, the better for the patient, said Amindra Arora, MB, BChir,
a professor of medicine and a consultant in gastroenterology and hepatology at the
Mayo Clinic in Rochester, Minn.

“You only have about 12 to 24 hours,” he said. “After that the
fluid resuscitation doesn't really make much difference. The die is cast by then,”
he said, in terms of organ damage and necrosis.

It can be challenging to determine precisely how much fluid to give, said Dr. Forsmark,
who cautions that doctors should keep a close eye on how much their patient can tolerate.
If the patient is older or has other health conditions, such as lung or kidney problems,
too much fluid can be potentially harmful, he said.

Until the symptoms resolve, pain control is essential, although no studies have identified
the optimal narcotic to use, the JHM review article said. Prophylactic antibiotics should be avoided unless there is a
clear sign of infection, the authors wrote.

And while the serum amylase and lipase levels are checked as part of diagnosis, the
bloodwork doesn't need to be repeated later, Dr. Gardner said. Sometimes clinicians
will continue to monitor those readings and base their management on whether they're
going up or down, he said. “But they really don't have any prognostic value.”

If the patient isn't improving after three to five days—for example, if he
or she is still having pain and is unable to take anything by mouth—then it
is time to order a CT scan, Dr. Arora said.

If gallstones are implicated, the gallbladder should ideally be removed during that
initial hospitalization, Dr. Forsmark said. He cited a study, published Sept. 26,
2015, in The Lancet, finding that patients whose gallbladders were removed before they went home had
a far lower chance of recurrent gallstone-related complications. In the six months after hospitalization, only 5% of patients who underwent immediate
surgery were readmitted for a related reason or died versus 17% of those whose operation
was postponed until after discharge.

Sometimes a delayed operation makes sense, such as when a patient is still recovering
from necrosis, Dr. Arora said. Otherwise, he said, “They should not be dismissed
with their gallbladder intact.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.